CC:Cough & similar(Peds)-FULL SOAP-Textarea

CC:[text name="variable_1" default=" "]
Subjective:
HPI: [textarea name="variable_44" default="Patient -initials- is a -age- -ethnicity- -male/female- who presents today with a chief complaint of --. Patient is an -established patient with the clinic--new patient to the clinic-. Patient is here today with -his/her- mom /dad /grandma /grandpa /who has written consent from legal guardian"]
[textarea name="variable_2" default="*****Patient appears fatigued / fatigued but relaxed / ill-appearing / makes good eye contact, speaks clearly and easily, no signs of respiratory distress"]
[textarea name="variable_3" default="*****Symptoms started -- days ago. Symptoms include cough / congestion / wheezing / dyspnea / runny nose / sore throat. Symptoms are relieved w/ OTC Tylenol w/ OTC cough medicine / Symptoms are mildly relieved w/"]
Drug Allergies:[text name="variable_45" default="NKDA."]
Medical History:[text name="variable_4" default="None."]

* ROS
-ENT:[textarea name="variable_6" default="Eyes: no corrective lenses or glasses. Ears: denies difficulty with hearing, tinnitus, vertigo, ear pain or discharge; Nose/Sinuses: denies nasal congestion, sneezing, sinus pressure/pain, and epistaxis. Teeth: denies issues. *****c/o eye dryness / discharge / itchiness / c/o ear drainage / pain / tenderness / tinnitus / vertigo"]
-Neck/Throat:[textarea name="variable_7" default="denies pain, lumps *****admits to sore throat / difficulty swallowing"]
-Cardiovascular: [textarea name="variable_8" default="denies chest pain, palpitations, or tachycardia. *****has cardiac history of"]
-Respiratory: [textarea name="variable_9" default="denies cough, congestion, wheezing, or dyspnea *****c/o cough, congestion, wheezing, dyspnea"]
-Gastrointestinal: [textarea name="variable_10" default="denies abdominal discomfort, heartburn, reflux; reports regular voids and stools w/no issues, denies vomiting, diarrhea, constipation *****c/o nausea, vomiting, diarrhea"]

Objective
* Vitals: HR [text name="variable_12" default=" "], RR [text name="variable_13" default=" "], WT [text name="variable_14" default="  lb ( % precentile)"], HT [text name="variable_15" default=" "], BMI [text name="variable_16" default=" "], [text name="variable_17" default="BP "], Spo2 [text name="variable_18" default=" "]

* Physical Exam
General: [textarea name="variable_19" default="Child appears age appropriate. Vitals noted and stable. Well developed. Well nourished. Well groomed. No signs of respiratory distress *****Child is ill-appearing / appears fatigued."]
HEENT: Head: [textarea name="variable_20" default="denies migraines/headaches"]
Eyes: [textarea name="variable_21" default="Conjunctivae noninjected, sclerae anicteric, lids without ptosis, edema, erythema, extraocular movements intact, pupils equal, round, and reactive to light *****BILATERAL watery eyes / purulent discharge / mucopurulent discharge / UNILATERAL / LEFT / RIGHT / watery eyes / purulent discharge / mucopurulent discharge"]
Ears: BOTH EARS: [textarea name="variable_22" default="TMs w/out effusion, mobile, non-bulging, gray, sharp landmarks. ***** TMs dull w/ effusion, mobile, non-bulging, gray, sharp landmarks / with air-fluid levels behind it / tympanic membrane is perforated / tympanic membrane is erythematous, bulging and non-mobile / tympanic membrane is erythematous, but is non-bulging and is mobile / ear drainage noted on exam / impacted cerumen"]
RIGHT:[textarea name="variable_23" default="TM w/out effusion, mobile, non-bulging, gray, sharp landmarks. ***** TM dull w/ effusion, mobile, non-bulging, gray, sharp landmarks / with air-fluid levels behind it / tympanic membrane is perforated / tympanic membrane is erythematous, bulging and non-mobile / tympanic membrane is erythematous, but is non-bulging and is mobile / ear drainage noted on exam / impacted cerumen"]
LEFT:[textarea name="variable_24" default="TM w/out effusion, mobile, non-bulging, gray, sharp landmarks. ***** TM dull w/ effusion, mobile, non-bulging, gray, sharp landmarks / with air-fluid levels behind it / tympanic membrane is perforated / tympanic membrane is erythematous, bulging and non-mobile / tympanic membrane is erythematous, but is non-bulging and is mobile / ear drainage noted on exam / impacted cerumen"]
Nose/Sinuses: [textarea name="variable_25" default="nares patent, no erythema, no drainage *****clear nasal drainage bilaterally / mucopurulent rhinorrhea bilaterally / dried mucus bilaterally"]
Mouth/Throat: [textarea name="variable_26" default="Non-inflamed bilaterally, uvula midline, no petechiae or exudate, Tonsils 1+; Teeth: Dentition normal for age, no significant carries noted *****Mild erythema / erythema to anterior arch / erythema to pharynx / Cobblestoning / Petechiae noted to pharynx / petechiae / exudate / tonsils surgically removed"]
Lymph Nodes: [textarea name="variable_27" default="No significant lymphadenopathy."]
Thyroid: [textarea name="variable_28" default="No thyromegaly; trachea midline without masses."]
Heart: [textarea name="variable_29" default="Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs."]
Lungs: [textarea name="variable_30" default="Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions; dry cough noted during exam"]
Abdomen: [textarea name="variable_31" default="Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention."]

*LABS: [text name="variable_32" default="None."]
*DIAGNOSTICS: [text name="variable_34" default="None."]

PREVENTATIVE HEALTH
Immunizations: [text name="variable_65" default="UTD."]

ASSESSMENT/PLAN
[textarea name="variable_37" default="J06.9 - ACUTE UPPER RESPIRATORY INFECTION, UNSPECIFIED. * Discussed symptomatic treatments, observation, and increasing fluid intake. Reviewed hygiene to prevent spread of infection including hand washing and hand sanitizing. * Discussed signs and symptoms of respiratory distress and to notify emergency services if noted."]
[textarea name="variable_40" default="R53.83 - OTHER FATIGUE. * Discussed the importance of R&R, increasing hydration to thin secretions, and drinking warm fluids with honey."]
[textarea name="variable_39" default="R05.1 - ACUTE COUGH. * Discussed the importance of R&R, increasing hydration to thin secretions, and drinking warm fluids with honey."]
[textarea name="variable_41" default="J01.90 - ACUTE SINUSITIS, UNSPECIFIED. * Start amoxicillin-clavulanate 400mg/57mg, 7 ml, BID x 10 days * Suspect acute bacterial rhinosinusitis, will start ATX therapy and follow-up in 2-3 days. * Use OTC children’s nasal saline spray for congestion. * Discussed the importance of R&R, increasing hydration to thin secretions, and drinking warm fluids with honey. * Educated on coughing up secretions and blowing nose instead of swallowing secretions to help avoid upset stomach. * Use warm, moist compresses over forehead, eyes and sinuses to help alleviate symptoms."]
[textarea name="variable_42" default="B97.4 - RESPIRATORY SYNCYTIAL VIRUS CAUSING DISEASES CLASSD ELSWHR. * Obtained rapid RSV - negative."]

Follow-up: [text name="variable_60" value="2-3 days"]
CC:
Subjective:
HPI:


Drug Allergies:
Medical History:

* ROS
-ENT:
-Neck/Throat:
-Cardiovascular:
-Respiratory:
-Gastrointestinal:

Objective
* Vitals: HR , RR , WT , HT , BMI , , Spo2

* Physical Exam
General:
HEENT: Head:
Eyes:
Ears: BOTH EARS:
RIGHT:
LEFT:
Nose/Sinuses:
Mouth/Throat:
Lymph Nodes:
Thyroid:
Heart:
Lungs:
Abdomen:

*LABS:
*DIAGNOSTICS:

PREVENTATIVE HEALTH
Immunizations:

ASSESSMENT/PLAN






Follow-up:

Result - Copy and paste this output:

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